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Clinical Case Presentation SOAP

Formulate a professional nurse practitioner case presentation in a SOAP format.

Create a PowerPoint (PPTx) case presentation from one of your clinical experiences. Content should only be the relevant information. Use the SOAP format. Ensure that your presentation is HIPAA compliant.

Subjectice

Opener presentation of the patient (age/sex/presentation of issue with key past DX)

· History of present illness (HPI) (OldCarts)

· Other related past medical history, including social or cultural content

· Review of systems (ROS)

Objective

· Vital signs and physical exam on pertinent body systems

Assessment

· Assessment, including differentials and specific labs or X-rays reviewed

Plan

· Plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.

· Include cultural considerations that impact the patient both clinically and regarding social equality, diversity, and inclusion.

Support

· Explain the standard clinical guideline support and recommendations.

· Evaluate the case’s diagnostic results and treatment plan.

· Incorporate data, inferences, and reasoning of the plan and provide your evaluation.

· Explain expected outcome and associated epidemiology of the condition briefly, including the prognosis, with consideration of comorbidities, level of condition, and plan.

Format Instructions

Include the following:

· A design theme from PowerPoint

· Title, introduction, and conclusion slides

· 8–10 content slides

· Speaker notes, expanding content for each slide

· Voiceover

· At least four references

Assignment Requirements:

Before finalizing your work, you should:

· be sure to read the assignment description carefully (as displayed above);

· consult the grading rubric (located in Course Resources, Grading Rubrics submodule) to make sure you have included everything necessary; and

· utilize spelling and grammar checks to minimize errors.

Your clinical case presentation assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics;

· demonstrate use of elegant graphics and visuals; and

· use APA 7th edition format.

# 2 Assig

This assignment requires citations and references that are current and evidence driven. This assignment should be completed in 1-2 pages. Use first-person perspective such as “I saw a 3-year-old…”

1. Select a patient who was prescribed a medication (s) you provided care for. Provide date of visit.

2. Without giving any personal identification, provide the patient’s age, gender, reason for visit, and who presented with the patient.

3. What was your role (provider, observer, etc.) during this visit?

4. Provide a summary of the HPI and PMH that was collected.

5. What assessments (measurements, hearing, vision, etc.) were done?

6. Explain the type of physical exam. (focused vs. complete).

7. Explain abnormalities found, diagnosis, and any patient education or anticipatory guidance provided.

8. Explain if there were any treatment interventions including immunizations and give rationale. What medications, referrals, labs or screenings were ordered? How did you synthesize expert opinions on the utilization of medications in this young pediatric population? Provide rationale for each.

9. How did the visit end? Follow-up? Treatment plan?

10. How did you determine the patient and/or patient’s caregiver’s understanding of information you provided?

11. Explain your interaction with the patient and caregiver.

Give details about what you learned today and your thoughts about the encounter.

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